The Chronicles of EMS, if you’re living under a rock and you haven’t heard, is a cooperative effort between the Great Filmmaker Thaddeus Setla (EMSmedia.tv), the Remarkably Strong Paramedic Mark Glencourse (Medic999), and the “Ruggedly Handsome” firefighter/paramedic Justin Schorr (The Happy Medic). Their cooperative venture has taught me things that I’ve put to use in my own EMS practice that I believe have improved my care. Mark showed me the UK’s “Front Loaded” model and Justin has been talking about EMS providers being a gatekeeper to the emergency healthcare system. It’s a powerful collaboration. (Be sure to follow #CoEMS on twitter and become a fan of Chronicles of EMS on Facebook as well)

So here’s an example of what I mean. I can talk about this now because it’s been long enough that I can sufficiently muddle any possible trace back to the patient and fulfill any patient confidentiality concerns. I work in two very diverse service areas and cover approximately 35 different skilled nursing facilities at any one time. So in the time since the Chronicles of EMS has come out I’ve transported umpteen-hundred patients from those facilities and the patient I’m writing about could be any of those umpteen hundred. So there’s no way to violate confidentiality, Mmmm ‘Kay?

Anyway, some time ago I was dispatched as the ALS response to backup a BLS ambulance for the “unresponsive” patient at a skilled nursing facility. I arrived a few seconds after the ambulance did and carried my drug bag and EKG/Defib into the facility with the ambulance crew following close behind with their jump kit, the cot, and a backboard. After a few seconds in the facility, a staff member directed me to the Physical Therapy area of the facility which was a bit of a walk. When I got there, I saw three other staff members huddled around an elderly female patient who was seated in a reclining chair.

The staff members were fairly excited about the situation, as was the patient, who was very much conscious and alert. The story everyone told me at once was that the patient had finished her physical therapy session on her upper body to strengthen her shoulders and had been sat in the chair by the PT Assistant to rest. After a few minutes, the PT asst. came to check on the patient and found her unresponsive to verbal stimuli, by which I mean that the patient would not awake when spoken to. The PT asst. called the facility’s emergency response team and another staff member activated 911. When one of the nurses arrived, the patient awoke to a sternal rub and was quite surprised to be the subject of so much attention. She had been fully alert and cognitive since that time and when I asked her she denied any chief complaint other than being understandably emotional about the situation.

As I do with every patient after I rule out any immediate life threats I moved into a more detailed assessment. My lady here had skin that was Pink, Warm, and dry. Her pupils were PERRL and her Cincinatti Pre-hospital stroke scale was negative. Her Lungs were clear, her abdomen was soft and non-tender with normoactive bowel sounds, and her extremities were warm and had good pulses, motor, and sensation. Her blood glucose was well within limits, and so were all of her vital signs. All of my other assessment findings were not indicative of any acute abnormalities other than a complaint of slight shoulder pain and weakness which could have been indicative of either an acute MI or of a rigorous PT session. So, to be even more thorough, I hooked her up to my 5-lead EKG which showed normal sinus rhythm with some peaked T-waves. I then ran a 12-lead EKG which was admittedly probably better than mine is.

I asked the nurse “Has she had a potassium level drawn recently?” She looked through the patient’s chart and found out that the patient in fact had been tested for that two days prior and had been found to have a slightly elevated serum potassium level. Since they had been active witnesses to my assessment we agreed that other than for perhaps a bit too much potassium there was little chance of anything being wrong with the patient.

Since we were here in the US and not in the UK like Mark, where he can treat and release (or “Respond, not Convey”) I asked the patient if she wanted us to take her to the hospital. She didn’t want to go and said that she just wanted to go back to bed. When the staff members weren’t completely convinced that we shouldn’t transport her, I suggested that they call the patient’s primary care physician to ask him what his wishes were. The nurse did so, and called from her cell phone in front of us. She did a good job of explaining in detail the events of the call and our collective assessment findings, I provided my interpretation of the 12-lead EKG and chimed in with my assessment findings that I use in my acute care practice.

For his part, the doctor was amenable to treating the patient at the facility and stated that he was comfortable with us not transporting the patient. He ordered a few stat labs and requested that we leave a copy of the 12-lead for the patient’s chart, which I was happy to do. Bottom line: The patient signed a refusal and was happy not to have to go to the hospital; The skilled-nursing-facility staff members were happy that the patient was in no immediate danger; and I was happy that we had made the best possible decision for the patient and that I wasn’t exposing her to unnecessary risk.

What happened here is exactly one of the things that I and others have been talking about with the EMS 2.0 movement: EMS people having the ability to make an educated and sound decision about the best possible healthcare options for our patients and not simply having to activate the full emergency healthcare system for every complaint. This case had every element of that and I believe that the patient being redirected through her normal primary healthcare pathway was a much better choice than taking her to the emergency room.

Heck, since there turned out to be no adverse results to this, and since the patient was probably on Medicare, I would surmise that I’ve ended up saving the taxpayers thousands of dollars in unneccesary costs… Huh? Can educating and empowering paramedics “save” the healthcare system in the US by creating a huge savings in the most expensive form of providing healthcare?

What do you think? Did I do good?

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I think you did more than good, you did exactly what I would have done in the same set of circumstances. Not only do I think you did the right thing, I do that “type of thing” on a regular basis. It's not the 1st and I am sure that it won't be the last time we get toned out for an “unknown type medical” or “medic assist” or whatever and we get there and the patient was feeling a little peaked before arrival or a little dizzy or had a “bad belly”. We do a complete assessment including EKG (if warranted) and then present them with options: “We can certainly take you to the hospital if you'd like. Chances are you will be in the E.R. the rest of the night and you will not be seeing your doctor. Yes I realize you had surgery at that hospital 7 years ago and your doctor has admitting privileges but tonight you will see an E.R. doc and then they will refer you. The other alternatives are that you call your doctor and make a follow up appointment, you drive (or have someone drive you) to the E.R./clinic or you stay home and call us back if anything at all changes”. We don't refuse transport (obviously) and ALWAYS (whether we mean it or not) make it clear that we'll transport if that is what they prefer. These scenarios are driven in no small part by the call circumstances themselves, heck it's not the 1st or last time we try as hard as we can to get someone to go but if it makes sense medically and there is no danger to the patient we make them aware that they have other ways to get care.

I think that you definitely did the right thing because it a) was medically in the best interest of the patient and b) is what the patient wanted. This is something I've done quite a few times myself and I see no reason why this sort of thing can't be done everywhere.

I think it's important that we remember the perspective of the patient. Ultimately, they are the customer and more often than not can make good decisions regarding their own care. Sure there are times when a patient may not realize the seriousness of their condition or be altered mentally to be unable to make a correct decision, and vice versa where a patient may be over concerned or mentally able to make a decision that is to medical professionals the wrong decision… but in the end it really all is for them.

The MD doesn't even enter into it in my opinion. If the patient wants to stay and I have no reason to take them, they stay plain and simple. We already have this option, it's just legally filed under Patient Declines Transport.The facility can only override the patient's wishes if they have medical power of attorney (at least in this state).Sounds like the poor woman fell asleep in the chair. I think we need to change the name of your facility to Not-all-that-skilled.EMS 2.0 would give you the ability to not only leave her there, but notify the MD and the facility manager as to the condition and disposition through a central network. You know, the one they currently use to bill and refuse care.

Again Chris, completely agree with everything you say, however, here is the real humdinger!

I dont think this is enough for EMS 2.0. Yup it is a great start, but it is ultimately relying on the patient saying that they do not want to go.

EMS 2.0 should and will allow the assessing paramedic to do his/her full assessment, and then once all findings are complete make a clinical decision as to whether the patient requires further care at another facility.

The big step is to chance from asking the patient if they want to go to hospital, to instead, informing them that there is no clinical need for them to attend the ER at that moment in time. Not only is that a huge jump for the US systems of providing pre-hopsital care, but it will also be an ennormous jump for the paramedic actually delivering the care!

Again Chris, completely agree with everything you say, however, here is the real humdinger!

I dont think this is enough for EMS 2.0. Yup it is a great start, but it is ultimately relying on the patient saying that they do not want to go.

EMS 2.0 should and will allow the assessing paramedic to do his/her full assessment, and then once all findings are complete make a clinical decision as to whether the patient requires further care at another facility.

The big step is to chance from asking the patient if they want to go to hospital, to instead, informing them that there is no clinical need for them to attend the ER at that moment in time. Not only is that a huge jump for the US systems of providing pre-hopsital care, but it will also be an ennormous jump for the paramedic actually delivering the care!

You did as I would have done and maybe a little more. I deal with these types of situations quite often and have developed a little rule that I apply when deciding how the patient is to be triaged.

If they know WHO they are, WHERE they are, HOW they are, and WHY I'm standing there…they call the shots. Now, obviously I have to use some common sence when the patient may not be fully aware of their condition or the extent of their “injury”, and I will not hesitate to encourage further evaluation if it is warrented.

I seem to remember something about consent to treat and that other thing…..kidnapping I believe it is, that we must take into consideration. I do wish the facility staff understood those rules we have to play by before they start demanding that we transport because of their “policy” or just because the doctor said so.

Again Chris, completely agree with everything you say, however, here is the real humdinger!

I dont think this is enough for EMS 2.0. Yup it is a great start, but it is ultimately relying on the patient saying that they do not want to go.

EMS 2.0 should and will allow the assessing paramedic to do his/her full assessment, and then once all findings are complete make a clinical decision as to whether the patient requires further care at another facility.

The big step is to chance from asking the patient if they want to go to hospital, to instead, informing them that there is no clinical need for them to attend the ER at that moment in time. Not only is that a huge jump for the US systems of providing pre-hopsital care, but it will also be an ennormous jump for the paramedic actually delivering the care!

You did as I would have done and maybe a little more. I deal with these types of situations quite often and have developed a little rule that I apply when deciding how the patient is to be triaged.

If they know WHO they are, WHERE they are, HOW they are, and WHY I'm standing there…they call the shots. Now, obviously I have to use some common sence when the patient may not be fully aware of their condition or the extent of their “injury”, and I will not hesitate to encourage further evaluation if it is warrented.

I seem to remember something about consent to treat and that other thing…..kidnapping I believe it is, that we must take into consideration. I do wish the facility staff understood those rules we have to play by before they start demanding that we transport because of their “policy” or just because the doctor said so.

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